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The Impact of Abortion Laws on the Rates of Maternal Mortality through Unsafe Abortion

In modern politics, and throughout the history of reproductive rights discussions, access

to abortion has been hotly debated. Abortion and birth control services, in general, have always

been fairly prominent in the news media. The Roe v. Wade decision was made in 1973 (Oyez,

n.d.), but the pro-life v. pro-choice battle continues to wage on. When people have limited or no

access to legal and safe abortion services, it is natural to think that the rate of abortions will

decrease. However, in practice, the rate of illegal and unsafe abortions tends to increase (Latt,

Milner, & Kavanagh, 2019). Legislation pertaining to the access of biosex females to abortion

services may have an impact on the rates of maternal mortality through unsafe abortions. When

pregnant biosex females have an unwanted pregnancy and wish to terminate it, but there isn’t

adequate infrastructure or service care providers, they often turn to unsafe abortion as a means of

resolution (Okonofua, 2006), however, this may be radically increasing the rates of maternal

mortality in developing and developed nations alike (Haddard & Nour, 2009). It is important for

patients and voters to know about the impacts of abortion legislation to inform their voting and

understand what is factually correct, from what may be state-mandated and/or unsupported

claims when seeking reproductive care services. This topic is important to me as I hope to work

in global or national health politics, specifically in the realm of increasing accessibility to

maternal health care and family planning services, as stabilizing population growth is critical to

the development of a nation (Sinding, 2009).

Abortion is defined as “the deliberate termination of a human pregnancy, most often

performed during the first 28 weeks of pregnancy” (English Oxford Living Dictionaries, n.d.,

para. 1). Globally, 26 countries still completely prohibit abortions, 37 countries prohibit all
abortions unless mandatory for maternal survival, 36 countries prohibit abortions unless it is to

protect a woman’s health, and 24 countries prohibit abortions unless necessary to protect a

women’s mental and physical health (Center for Reproductive Rights, 2014).

In the United States, currently, 42 states require an abortion to be performed by a licensed

physician, with 19 states requiring an abortion be performed in a hospital setting, and 19 states

requiring the involvement of a secondary physician (Guttmacher Institute, 2019). Forty-three

states prohibit abortions after a specific point in the pregnancy. In 45 states individual health care

providers are allowed to refuse participation in abortion services. Eighteen states mandate

counseling prior to an abortion, 13 of which mandate doctors to counsel on the unsupported

claims that fetuses can feel pain, eight of which mandate doctors to counsel on the unsupported

claims that there are long term mental health consequences, and five of which mandate doctors to

counsel on the unsupported claims that there is a link between abortions and breast cancer.

To provide a brief history of abortion law in the United States, in 1973 the Supreme

Court (SCOTUS) made the ​Roe v. Wade d​ ecision declaring that under the right to privacy of the

Due Process Clause of the 14th Amendment, women were legally able to access abortions (Oyez,

n.d.). In the 1992 ​Planned Parenthood v. Casey​ decision, SCOTUS allowed states to regulate

abortion access, as long as it did not place an undue hardship on the woman, which invalidates

the rule that women needed to notify their spouse if they have an abortion (​Oyez, n.d.)​. The

Partial-Birth Abortion Ban Act of 2003 banned late-term abortions and was reinforced by the

2007 case of ​Gonzales v. Carhart (​ Justia, n.d.).

Now, we’ll look at u​ nsafe ​abortion specifically. It is defined as “terminating an

unintended pregnancy carried out either by persons lacking the necessary skills or in an
environment that does not conform to minimal medical standards, or both” (WHO, 2003, p. 12).

There are three typical ways to conduct an unsafe abortion. The first method is by inserting a

sharp object through the cervix to pierce and detach the amniotic sac from the womb, a common

object used for this is a wire coat hanger, hence the colloquial phrase “coat hanger abortions”

(Haddard & Nour, 2009). Another method is by ingesting toxic chemical mixtures like peppers,

herbicides, or cleaning solvents, or inserting them into the vagina or rectum. Physical exertion

and illegal self-induced abortion medication have also historically been used for inducing

abortions. “Coat hanger abortions” can lead to infection, genital trauma, and perforation of the

uterine wall, as well as piercing of other internal organs, which can lead to hemorrhaging and

bleeding out. If the fetus is not successfully aborted by the mother, there can be fetal

complications. Anything ingested by or inserted into the woman can lead to infection, toxic

shock, poisoning, and maternal mortality.

Maternal mortality is defined as “​ the death of a [biosex] woman while pregnant or within

42 days of termination of pregnancy” (WHO, n.d., para. 2), this can pertain to any length of

pregnancy, and the cause must pertain to pregnancy, but it cannot occur accidentally or

incidentally.​ The leading causes of maternal mortality globally are hemorrhaging, hypertensive

diseases, sepsis or infection, obstructed labor, and abortion, as well as other direct, indirect, and

unclassified causes (Ronsmans & Graham, 2006).

As discussed above, issues vary when looked at in a local or global context. Rather than

looking at policy variance, the rates of maternal mortality and how they vary based on different

global regions will instead be discussed. The Maternal Mortality Ratio (MMR) is the number of

deaths, as defined above, for every 100,000 live births in a given population (Ronsmans &
Graham, 2006). For the purposes of clarity and removing unnecessary decimals, we will be

discussing the MMRs using only the first of the aforementioned numbers, the number of deaths,

under the assumption that it will be further divided by 100,000. For example: If a country has an

MMR of 297/100,000, or, .00297, it will be referenced as 297. In 2015, the MMR for

sub-Saharan Africa was 546, and for South Asia it was 182 (UNICEF, 2017). In the Middle East

and North African region, the MMR was 110, with an MMR of 68 for the Latin American and

Caribbean region, the East Asian and Pacific region had an MMR of 62, and the Central and

Eastern European nations had an MMR of 25. For lesser developed countries (LDCs) overall the

MMR was 436, and globally the MMR in 2015 was at 216.

Looking at the raw and unadjusted data for the United States alone, there was an increase

in the MMR from 9.8 to 21.5 between 2000 and 2014 (MacDorman, Declercq, Cabral, &

Morton, 2016), even though globally there had been a decrease by nearly half between 1990 and

2015 (UNICEF, 2017).

As of 2006, worldwide, roughly 13% of maternal deaths from pregnancy-related causes

each year can be attributed to unsafe abortions (Okonofua, 2006) and every eight minutes, as of

2009, a woman in a developing nation experiences the fatal consequences of complications that

arise from an undergoing an unsafe abortion (Haddard & Nour, 2009). For the regions with the

highest rates of maternal mortality, sub-Saharan Africa and South Asia, the leading causes of

mortality are hemorrhaging, with the second leading causes as indirect and other direct for each

country respectively (Ronsmans & Graham, 2006). While, as of 2017, there are an estimated 25

million unsafe abortions performed every year, 97% of which occur in LDCs (Guttmacher

Institute, 2017), a precise number for deaths that can be attributed to unsafe abortion is unknown
(Ronsmans & Graham, 2006). But, it is estimated that MMRs specifically from unsafe abortions

are 37 for sub-Saharan Africa, 23 for Latin America and the Caribbean, and 12 for South Asia.

However, there are much higher estimates when looking at these rates on a smaller scale,

especially in countries where it is difficult to obtain an abortion either due to issues of legality, or

issues of accessibility. Hospitals in Côte d’Ivoire and Senegal reported one-third of all of their

maternal deaths occurred due to complications from an unsafe abortion.

It appears so far that there are two main issues in play, whether obtaining an abortion is

legal, and if so, whether obtaining a safe abortion is accessible. First, let us look at legality.

Severities of abortion laws can be broken down into seven main flexibility categories with a

rating of one being the most strict/least flexible and a rating of seven being the least strict/most

flexible: one, abortion only to prevent maternal fatality is permitted, two, abortion to preserve

maternal physical health, three, abortion to preserve maternal mental health, four, abortion to

terminate a pregnancy as a result of rape or incest, five, abortion due to predictions of fetal

disability, six, abortion for maternal economic or social reasons, seven, abortion permitted for

any reason (Latt et al., 2019). Examined from 162 countries, the mean (average) flexibility score

of 3.67 corresponded to an MMR of 367 between 1985 and 1989, whereas the mean flexibility

score of 4.1 corresponded for an MMR of 186 between 2010 and 2013. This data demonstrates

an inverse relationship between the flexibility score assigned to a country and their MMR; a

country with a high flexibility score, or, less strict abortion laws, will have a low MMR. This

suggests that when abortion services are sanctioned by the government, the number of maternal

deaths will, generally, decrease.

Next, we’ll look to accessibility. Just because a service may be legalized, if there isn’t an

appropriate time, place, or provider for that service, then it may be very difficult to obtain it (Latt

et al., 2019). Additionally, if women seeking an abortion are not informed of the legal change, of

where/how they are allowed to obtain an abortion, or whether they are within their legal right to

do so, then the tangible change in rates of mortality may not change by much, or at all. In the

United States, the MMR is climbing, contrary to that of the rest of the world (MacDorman et al.,

2016). This can be attributed to, as of January 2018, 40 U.S. states having enacted at least one of

the five following abortion restrictions​: clinically unnecessary regulations on abortion clinics,

mandatory counseling created to dissuade abortions, mandatory waiting periods before obtaining

an abortion, requiring parental involvement for minors, or prohibiting the use of state funding to

pay for abortions, even in medically necessary cases (Guttmacher Institute, 2019). This is legal

under the aforementioned case of ​Planned Parenthood v. Casey​ which made it illegal for states

to place an undue hardship on women, which was a fairly subjective definition (Oliver, 2016).

The ruling effectively said that states could make women jump through a ​few h​ oops to get an

abortion, but not ​too many​ hoops. States can make it so difficult for women to obtain an abortion

to the point where there is only one abortion clinic in the entire state and if an abortion-seeking

person comes from a low-income background, while it is technically, legally, possible for them

to obtain an abortion on paper, in practice, it physically cannot happen.

Looking at the sources of the data gathered and presented here, I have few complaints

and/or concerns. The most primary of them is looking at data generalization based on region. If

there are any outliers in the MMRs gathered between countries in a region, how are those going

to affect the overall MMR for the region. A further breakdown by UNICEF of these would be
excellent to examine any potential outliers that may artificially skew the region’s MMR. This

would also allow the ability to research that nation specifically, to understand why the MMR of

that nation is so dramatically different from its close-by counterparts. Another concern I have is

how the recency of and ability to gather certain sets of data impacts the analysis of that data.

Most of the data examined were gathered within a similar timeframe, but for many countries, it

seems like it may be difficult to gather adequate, accurate, and recent totals, especially if that

country does not conduct comprehensive and frequent censuses. Aside from these, I have little

concern about the data these articles put forth. There is a reasonable and appropriate line of logic

for the conclusions drawn from these articles, and the data gathered seems to appropriately fit the

arguments of the articles. It appears that the most effective abortion legislation for reducing

maternal mortality is a level 7 (open access to abortion services), paired with an increase in

maternal care and family planning facilities and services. A further question I plan to research is

how the number of designated reproductive care facilities per person, combined with general

access to contraceptives within a population, impacts the total fertility rate of a country as well as

the infant mortality rate of that country.

Overall, it is important for patients, voters, and legislators to understand what is currently

in place, and how someone seeking an abortion could legally and safely go about doing so. When

someone is faced with an unwanted pregnancy, if they do not have government sanctioned,

easily accessible family planning and reproductive care services that can provide them with the

abortion that they want or need, then they may turn to unsafe and fatal methods to terminate the

pregnancy. Patients need to be aware of the rights they have walking into a medical office where

they live, and if it is reasonably feasible for them to go somewhere else to obtain a service that
their current place of residence may not afford them. Voters need to understand what the real

consequences are when they cast a ballot to elect someone who opposes access to abortions, or

vote on local ballot measures that may harm some of the most vulnerable people in a population.

Strict abortion laws do not decrease the rates of abortions, but instead, increase the rates of

unsafe abortions, thus increasing the rates of maternal mortality. Strict abortion laws harm more

people than some groups argue they are theoretically saving. It is important for legislators to

understand that, whether their motive is truly helping people, or simply getting re-elected,

pushing harmful and detrimental policies will not help anyone. In my future, I plan to advocate

for increases in the accessibility to family planning and reproductive care services. These are

absolutely vital, and I hope to have a substantial impact on the ability of people to gain such

critical care.

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